The CALMER Approach: Teaching Learners Six Steps to ... - STFM

For the Office-based Teacher of Family Medicine
William Huang, MD
Feature Editor
Vol. 36, No. 7
Editor’s Note: Encounters with “difficult” patients can be challenging and stressful to learners and even
clinical teachers. In this month’s column, Heidi Pomm, PhD, and colleagues discuss a practical approach
that teachers and learners can use to alleviate the stress in difficult patient encounters and better
handle the patient’s needs.
I welcome your comments about this feature, which is also published on the STFM Web site at
www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it
to their preceptors (with the appropriate Family Medicine citation). Send your submissions
to williamh@bcm.tmc.edu. William Huang, MD, Baylor College of Medicine, Department of Family
and Community Medicine, 3701 Kirby, Suite 600, Houston, TX 77098-3915. 713-798-6271. Fax: 713-
798-7789. Submissions should be no longer than 3–4 double-spaced pages. References can be used
but are not required. Count each table or figure as one page of text.
The CALMER Approach: Teaching Learners Six Steps
to Serenity When Dealing With Difficult Patients
Teaching learners to handle encounters
with “difficult” patients is not
easy since these encounters may tax
the coping resources of even the
most skilled or experienced physician.
Difficult patients include those
who are “medically challenging,
interpersonally difficult, psychiatrically
ill, chronically medically ill,
or lacking in social support.” 1 Studies
have found that they are older;
have more acute, chronic, and psychosocial
problems; take more
medications; and more frequently
are divorced or widowed and from
a lower social class. 2,3 Specific be-
(Fam Med 2004;36(7):467-9.)
Heidi A. Pomm, PhD; Edward Shahady, MD; Raymond M. Pomm, MD
From the St Vincent’s Medical Center Family
Medicine Residency Program, Jacksonville, Fla,
and the Department of Family Medicine and
Community Health, University of Miami (Dr H
Pomm); the Department of Family Medicine and
Rural Health, Florida State University (Dr
Shahady); and the Impaired Practitioner’s Program,
Fernandina Beach, Fla, and the Department
of Psychiatry, University of Florida (Dr R
Pomm).
haviors of patients that make the
encounter difficult include their
being overly dependent, demanding,
manipulative, or noncompliant.
4,5 One study found that family
physicians rated approximately
30% of their 722 patient encounters
as troubling. 3
However, the problems surrounding
these encounters are often not
solely due to the patient. Physicians
must understand how their own attitudes
and behavior may contribute.
3,5-8 Reactions toward difficult
patients can range from acquiescence
and inward anger to more
active scorn and disrespect. 9 These
negative reactions may result from
these patients being “an uncomfortable
reminder of the doctor’s inadequacy
and impotence.” 10 In addition,
a physician’s failure to carefully
listen, show empathy, or establish
trust may result in an inadequate
understanding of the
patient’s history and issues. 11
The CALMER approach assists
physicians in reducing the affective
467
distress associated with interactions
with problem patients. This approach
combines elements from
Prochaska and DiClemente’s
“Stages of Change” model, 12
Shahady’s “Rule of Five, ”8 and
Gillette’s “Practical Approach for
Managing Problem Patients.” 5 In
addition, the CALMER model also
incorporates strategies derived from
cognitive-behavioral therapy. 13
Office-based teachers may find
the CALMER approach to be a
structured, easy-to-remember
model that is especially helpful during
encounters where the learner
has difficulty dealing with a
patient’s demands, feels frustrated
with a particular patient, makes derogatory
remarks about a patient,
wants to transfer care of a patient
to someone else, and is not interested
in helping an individual patient
and/or even the teacher has
difficulty dealing with a patient.
The CALMER approach consists
of six steps, several of which
only take moments to complete: (1)

468 July-August 2004 Family Medicine
Catalyst for change, (2) Alter
thoughts to change feelings, (3)
Listen and then make a diagnosis,
(4) Make an agreement, (5) Education
and follow-up, and (6) Reach
out and discuss feelings.
(1) Catalyst for Change
In this step (either before, during,
or after an interaction with a difficult
patient), physicians should remind
themselves of what they can
and cannot control about the situation.
In most cases, the responsibility
to change behavior lies with the
patient. Physicians cannot control
the patient’s behavior, but they can
control their own reaction and try
to be helpful by offering practical
advice. After identifying the
patient’s current stage in the “Stages
of Change” model, 12 (Table 1) the
physician can serve as a catalyst for
change by giving recommendations
on how the patient can advance to
the next stage of change and eventually
overcome the problem.
(2) Alter Thoughts
to Change Feelings
Cognitive-behavioral therapy
posits that the only way individuals
can control their reactions (feelings)
is to alter their thoughts about
the situation. 13 Either before, during,
or after the doctor-patient interaction,
physicians should identify
which feelings they are experiencing
in response to the patient and
then ask how these feelings might
be affecting the physician-patient
relationship and the management
plan. Physicians should remind
themselves not to take the patient’s
behavior personally, since this is
likely the patient’s way of responding
and behaving in many areas of
his/her life (not just in interactions
with the physician). It is also suggested
that the physician explore
and understand possible underlying
reasons or answers for the patient’s
behavior (past abuse, poor finances,
loneliness, etc). Lastly, physicians
should ask themselves, “What can
I tell myself about this situation that
will make me feel less (angry, dis-
gusted, etc)?” In doing so, they are
then able to alter or change their
thoughts and therefore feel less distressed.
(3) Listen and Then
Make a Diagnosis
As a result of a physician’s negative
response to a difficult patient
encounter, he/she may not accurately
hear what the patient is trying
to verbally or nonverbally communicate.
11 This can lead to severe
errors in diagnosis. By engaging in
the first two steps described above,
the physician will be better
equipped to truly hear what patients
are trying to communicate. This
will improve the likelihood of making
more-accurate diagnoses and
will lead to better working relationships
with patients.
(4) Make an Agreement
This step is focused solely on
making an agreement with the patient
to continue the doctor-patient
relationship. The physician might
say to the patient, “So, after all we
have discussed, it is my understanding
that you would like to continue
to see me, and we have agreed that
we will work together to keep you
as healthy as possible. Is that your
understanding too?” It is important
to confirm that the patient understands
and agrees with the proposal.
Table 1
Stages of Change
• Precontemplation Patient denies or minimizes problem
• Contemplation Patient acknowledges problem but not ready to change
• Preparation/determination Patient commits to time and plan for resolving the problem
• Action Patient makes daily efforts to overcome problem
• Maintenance Patient has overcome problem for at least 6 months
but must remain vigilant
• Relapse Patient has gone back to problem behavior
Adapted from Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional
boundaries of therapy. Homewood, Ill: Dow-Jones-Irwin, 1984. 12
In addition, if the patient has insight
into the problem behavior, the physician
might say, “We have agreed
to work on this problem (specify
exactly what the problem is) together.
Is that your understanding
as well?” This step helps both the
physician and the patient increase
their awareness that they are making
a conscious choice to continue
their relationship and work on the
patient’s concerns, which in turn
increases perceived control for both
parties.
(5) Education and Follow-up
After the doctor and the patient
agree to continue their relationship
and work together, how they will
accomplish this needs to be addressed
as specifically as possible.
Physicians should temporarily let
go of their own agenda (even
though they feel it is more appropriate)
and give a “doable” recommendation
tailored to where the
patient is in the “Stages of Change”
model. 12 For example, for a patient
contemplating whether to quit
smoking, the physician may prescribe
homework such as: “Over the
next 2 weeks, I’d like for you to
write down your feelings right before
you reach for a cigarette. Think
about the ‘pros’ and ‘cons’ of picking
up that cigarette without judging
yourself on the choice you ulti-

For the Office-based Teacher of Family Medicine
mately make. We’ll talk about your
experience with this homework assignment
when I see you back in 2
weeks. Is that okay?” Similarly, the
physician can encourage a patient
in the precontemplation stage to
begin thinking about the issue at
hand. The physician and patient
should agree on the “homework assignment”
and the time frame in
which it is to be completed.
(6) Reach Out and Discuss
Your Feelings
It is commonly believed that
most doctors are “islands” and are
generally reluctant to ask for help.
Yet, as stated earlier, even the most
skilled and competent of physicians
will at times feel great distress following
an interaction with a difficult
patient. After engaging in the
preceding steps, it is suggested that
physicians ask themselves, “How
do I now feel about this patient and
his/her behaviors?” It is also important
for physicians to identify how
they will care for themselves the
next time a patient elicits these
types of feelings. Discussing these
feelings and the difficulty of the
experience with a trusted colleague
or friend can be of great assistance
since a wealth of research attests to
the beneficial effects of social support.
14,15 When dealing with difficult
patients, physicians do not have to
feel alone.
Although numerous articles have
been published on difficult doctorpatient
interactions, only a few
models have been proposed to help
physicians decrease the distress frequently
associated with these interactions.
The CALMER approach
incorporates six steps that physicians
can utilize to feel more in control
and less distressed during these
types of patient encounters. By taking
the time to guide learners
through the individual steps of this
approach, the office-based teacher
may increase learners’ self-efficacy
in handling difficult patient encounters
since the CALMER approach
focuses on what learners can control
(their own reactions) and less
on what they ultimately cannot control
(the patient’s behavior). A
CALMER learner results in a more
serene learner, who is better able to
care for patients in need.
Corresponding Author: Address correspondence
to Dr Heidi Pomm, Family Medicine Residency
Program, St Vincent’s Medical Center, 2708 St
Johns Avenue, Jacksonville, FL 32205. 904-308-
8482. Fax: 904-308-2998. hpomm001@
stvincentshealth.com.
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